Cortland Center

In the surveyor’s words

From the most serious findings on record at Cortland Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF804Jul 24, 2023

  Based on interview, observation and record review, the facility failed to ensure meals served looked appetizing and were served at palatable temperatures. This had the potential to affect all residents receiving meals from the kitchen with the exception of Residents #1 and #10 who received no nutrition by mouth. The facility census was 49. Findings include: Interview on 07/17/23 at 2:08 P.M. with Resident #3 revealed hot foods were served cold upon meal service. Interview on 07/17/23 at 2:21 P.M. with Resident #45's sister revealed while at the facility, Resident #45 did not eat the food because Resident #45 said it did not taste good. Interview on 07/17/23 at 2:32 P.M. […]

• No harm, potential for more than minimal, widespreadF727Dec 14, 2021

  Based on interview, review of staffing schedules, and review of the Benefits Improvement and Protection Act (BIPA) daily staffing postings, the facility failed to maintain the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of the facility staffing schedules and daily BIPA staffing postings dated between 11/13/21 and 12/13/21 revealed no RN was present working in the facility on 11/14/21, 12/04/21, 12/11/21, and 12/12/21. Interview with Human Resources (HR) #511 on 12/13/21 at 10:20 A.M. […]

• No harm, potential for more than minimal, isolatedF880Jan 29, 2026

  Based on observation, interview, record review, review of camera video footage and facility policy review, the facility failed to ensure Resident #41 had appropriate transmission-based precautions implemented. This affected one (Resident #41) out of three residents reviewed for infection control. The facility census was 62.Findings include:Review of Resident #41's medical record revealed an admission date of 12/25/25 with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, saddle embolus of pulmonary artery with acute cor pulmonale, urinary tract infection and extended spectrum beta lactamase (ESBL) resistance.Review of Resident #41's physician orders dated 12/25/25 revealed Contact Precautions/Isolation related to ESBL, every… […]

• No harm, potential for more than minimal, isolatedF692Jun 26, 2025

  Based on record review, staff interview and facility policy review, the facility failed to ensure accurate weights were obtained for Resident #31 and Resident #46. This affected two (Residents #31 and #46) of six residents reviewed for nutrition. The facility census was 62. Findings include: 1. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including iron deficiency anemia, intellectual disabilities, gastro-esophageal reflux, deficiency of B vitamins, hyperlipidemia, [NAME] crisis, depression, dysphagia, and intestinal malabsorption. Review of Resident #31's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #31's cognition was intact and was independent for eating. […]

• No harm, potential for more than minimal, isolatedF695Jun 26, 2025

  Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #162 had a physician's order for oxygen. This affected one (Resident #162) out of one resident reviewed for respiratory care. This had the potential to affect 18 (Residents #2, #4, #7, #10, #12, #17, #18, #28, #32, #39, #40, #44, #46, #48, #53, #113, #166, and #168) identified by the facility on oxygen. The facility census was 62. Findings include: Review of the medical record for Resident #162 revealed an admission date of 06/20/25 with diagnoses including fracture of right femur, hypertension, chronic kidney disease, and altered mental status. […]